2 T he International Network of Health Pro- Pro-moting Hospitals and Health Services (HPH)
2.3 Phase 2: Testing the concept and further devel- devel-oping network structures (1993-1997)
Table 6: Milestones of HPH development in phase 2
Phase 2: Testing the concept & further developing network structures (1993-1997) 1993-1997 Conducting of European Pilot Hospital Project (EPHP)
1993- Annual International HPH Conferences, International HPH Newsletter 1995- Establishing of national and regional HPH networks
1995- Annual HPH networks coordinators´ workshop
1996 Workshop: The Health Promoting Hospital in the European Union, Vienna 1997 The Vienna Recommendations on Health Promoting Hospitals
The European Pilot Hospital Project of Health Promoting Hospitals (EPHP) started in 1993 with 20 hospitals of different size, type and specialization, located in 11 European coun-tries7 (compare also Pelikan et al. 2001). The project was coordinated by the LBISHM in Vi-enna.
With the start of the European Pilot Hospital Project of Health Promoting Hospitals (EPHP) in 1993, further international network structures were established. These included an annual international conference and an international HPH Newsletter. While these media served to inform and involve a wider interested public, semi-annual business meetings of the EPHP were also held for purposes of project coordination between 1993 and 1997. Case stud-ies on the experiences of the hospitals that participated in the EPHP, and a summary of the project evaluation, were published by Pelikan et al. (1998).
In order to secure the continuity of HPH after the termination of the EPHP, a decision was taken by WHO-Euro in 1995 to establish national and – in countries with strong federal structures, such as the UK or Italy – also regional networks of Health Promoting Hospitals to support the further dissemination and implementation of the concept8. Conceptual considera-tions and papers developed at the time did not make a distinction between national and re-gional networks with regard to their rights and responsibilities towards the international HPH network.
The process of network establishment was also supported by the European Union with a specific workshop in Vienna in 1996 (Ludwig Boltzmann Institute 1996a). The workshop was
7 Austria: Rudolfstiftung Hospital, Vienna; Czech Republic: City Hospital Prague; France: Vaugirard Hos-pital, Paris; Germany: Klinikum Chemnitz; Alten Eichen HosHos-pital, Hamburg; St. Bernward HosHos-pital, Hildes-heim; Hospital St. Irmingard, Prien / Chiemsee; Philippshospital, Riedstadt; Greece: Areteion Hospital, Athens;
Hungary: Koranyi Hospital, Budapest; Ireland: James Connolly Memorial Hospital, Dublin; Italy: Vittore Buzzi Hospital, Milan; University Hospital Poland: Upper-Silesian Rehabilitation Centre Repty, Ustron; Padova;
Childrens’ Memorial Health Institute, Warsaw; Sweden: University Hospital Linköping; UK-England: Preston NHS Acute Hospitals NHS Trust; UK-Northern Ireland: Altnagelvin Hospital, Londonderry; UK-Scotland:
Stobhill NHS Trust, Glasgow; UK-Wales: Prince Philip Hospital, Llanelli.
8 This decision by WHO-Euro was preceded by the establishment of networks in Poland and Wales (both founded in 1993), and Bulgaria (founded in 1994) which had not participated in the EPHP project.
attended by representatives of EPHP hospitals from ten countries and by participants from six European Union states that had not been part of the EPHP, i.e. Belgium, Denmark, Fin-land, the Netherlands, Portugal, and Spain – Catalonia (Ludwig Boltzmann Institute 1996b).
When the EPHP was closed in 1997, a new HPH policy document – the Vienna Recom-mendations on Health Promoting Hospitals (WHO 1997) – were launched to support the implementation of national / regional HPH networks by new guidelines, but also to update the HPH framework provided by the Budapest Declaration in light of ongoing hospital and healthcare reforms, and to link HPH to other WHO policy papers, such as the Ljubljana Char-ter on Reforming Healthcare (World Health Organization 1996). Based on its experiences in the coordination of the Vienna model project “Health and hospitals” and the EPHP, the LBISHM in Vienna was entrusted with the coordination of the international network.
The 16 national and regional HPH networks that were founded during phase 2 of the de-velopment of the international HPH network are summarized in Table 7 below. While 13 of these can directly be traced back to the EPHP, two more were founded in relation with the aforementioned EU workshop.
Table 7: National / regional HPH networks founded in phase 2 of HPH development
Network Year of foundation
Foundation related to EPHP
EU workshop Direct indirect
1. Poland 1993
2. UK-Wales 1993
3. Bulgaria 1994
4. Germany 1995
5. Italy-Veneto 1995
6. Austria 1996
7. Finland 1996
8. Hungary 1996
9. Sweden 1996
10. UK-Northern
Ireland 1996
11. UK–England 1996
12. Belgium –
French Part 1997
13. France 1997
14. Ireland 1997
15. Italy-Piedmont 1997
16. Slovakia 1997
But, although HPH was now clearly starting to transform from the network of organiza-tions it had been during the EPHP period into a network of networks, the Vienna Recom-mendations’ specifications of networking remain superficial. The document merely introduced three options for hospitals to become a network member, i.e. via a national / regional HPH network, via a specific thematic network, or, if the hospital came from a country without a national / regional / thematic network, via direct membership in the international HPH net-work. Thus, the main focus of the document remained on individual hospitals, for which the document lists some criteria for participation. These include the endorsement of the Vienna Recommendations and the adherence to further specified rules and regulations established at the international as well as on national / regional levels9.
In addition to the Budapest Declaration, which basically had listed a number of potential action areas for HPH, the Vienna Recommendations started out with giving a rationale for health promotion in the hospital setting. The document stresses that hospitals, as the core setting of the health system,
have role model functions for other types of service providers, as they also have teach-ing, training and research functions in addition to providing services to patients;
represent large work forces for which they offer hazardous workplaces;
have contact to considerable proportions of a country’s population annually;
produce large amounts of waste;
consume a large amount of resources with relatively little public health outcome.The Vienna Recommendations formulated six fundamental principles for HPH:
1. promote human dignity, equity and solidarity, and professional ethics, acknowledging differences in the needs, values and cultures of different population groups;
2. be oriented towards quality improvement, the wellbeing of patients, relatives and staff, protection of the environment and realization of the potential to become learning organizations;
3. focus on health with a holistic approach and not only on curative services;
4. be centred on people providing health services in the best way possible to patients and their relatives, to facilitate the healing process and contribute to the empowerment of patients;
5. use resources efficiently and cost-effectively, and allocate resources on the basis of contribution to health improvement; and
6. form as close links as possible with other levels of the health care system and the community.
Compared to the contents specified in the Budapest Declaration, these principles appear more general and also more economy- and quality-driven, while four basic strategies for im-plementing the principles, which were introduced in the Declaration, take up and complement the contents originally lined out in the Budapest Declaration. These strategies are:
9 Regulations specified at the time which were however not explicitly mentioned in the Vienna Recommenda-tions included the demand to implement 3 health promotion projects and to pay an annual international mem-bership fee. In 1998, the demand to „have a smoking policy“ was added to these minimal memmem-bership require-ments, after a US non-smoking activist had complained about smoking patients and staff in front of entrances in Health Promoting Hospitals he had visited. These conditions are valid until to-date and are the basis of a con-tract each member hospital signs with the international HPH network secretariat for an initial period of 4 years after which membership can be prolonged for further 4-year periods ad infinitum.
fostering participation and creating commitment: the Vienna Recommendations called for par-ticipatory, health-gaoriented procedures and, in relation to that, for an active in-volvement of professional groups and professionals also outside the hospital, as well as for encouraging an active and participatory role for patients. They demanded a fo-cus on patients’ rights and wellbeing, on creating healthy environments for patients and relatives, and on creating healthy working conditions for hospital staff. To ensure implementation, the document stressed the importance of management commitment and demanded the inclusion of health promotion principles into daily decision-making processes.
improving communication, information and education: With regard to hospital staff, the strate-gy called for interprofessional cooperation and mutual acceptance of staff members to make hospital culture more conducive to the quality of life of hospital staff; this was understood as a precondition to improving the communication between hospital staff and patients (guided by respect and humane values) and an improved provision and quality of information, communication and educational programs and skill training for patients and relatives. Communication was further understood in the sense of devel-oping a common corporate identity, and of improving the hospital’s communication and cooperation with other social and health services and initiatives, with volunteer groups and organizations in the community.
using methods and techniques from organizational development and project management: The rec-ommendations called for a change and reorientation of hospital routines towards a learning organization, including training and education of personnel in areas relevant for health promotion, such as education, communication, psychosocial skills and man-agement. Furthermore, a training of project leaders in project management and com-munication skills was suggested.
learning from experience: last but not least, the Recommendations promoted an exchange of experiences in implementing HPH projects at the national and international level so that participating hospitals could learn from different approaches to problem solving.Health promoting hospitals should commit themselves to regional, national and inter-national exchange and communication.
The document, thus, framed the HPH network primarily as a platform of exchange, how-ever without specifying how and by whom this exchange should be organized.
Still, phase 2 of HPH can be considered a key developmental phase for the international, as well as the national and regional networks of HPH. Networks became the key HPH strategy, and mechanisms were put in place to foster exchange between hospitals and networks nation-ally and internationnation-ally. The participation in this exchange was strongly recommended to par-ticipating hospitals, and of the 46 national / regional HPH networks that were founded since the start of HPH until 2011, 16 – that is more than one third – were started between 1993 and 1997. Of these, twelve were established in a country or region that had participated in the EPHP, and two more had been founded in countries that had participated in the 1996 EU workshop.
While international documents, at that time, were quite open about the structures and tasks of national / regional networks, the establishment of these can be considered a first important step in making HPH a functionally differentiated network of considerable complexity, with an
international “umbrella” under which national / regional networks started to emerge. From 1995 onwards, HPH as a network has to be observed and described both on international and national / regional levels.